019200509-7-25-2024-15-AS-KNGN-D7HUCM-20240725152809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 07/25/2024
Date Signed: 07/25/2024 03:29:05 PM

Document Has Been Signed on 07/25/2024 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	PACIFICA SENIOR LIVING UNION CITY		FACILITY NUMBER:	019200509
ADMINISTRATOR:	ROBY, ROBERT B		FACILITY TYPE:	740
ADDRESS:	33883 ALVARADO NILES RD		TELEPHONE:	(510) 489-3800
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	110	CENSUS: 58	DATE:	07/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jeralyn May, Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE

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On 07/25/2024 at 9:00APM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced annual 1-year required inspection. LPA met with Administrator Jeralyn May. The facility’s fire clearance was approved for one hundred (100) ambulatory/non-ambulatory residents.

LPA toured the facility including but not limited to apartments, bathrooms, kitchen, common area, and back yard. The facility consists of 74 total apartments. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for residents is maintained at 71 degrees Fahrenheit. LPA observed lighting in rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared bathrooms was measured at 110.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-days of non-perishables and 2-days of perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Sprinkler system was last serviced on 11/1/2023. Fire extinguisher was last services on 12/6/2023. Fire drill last conducted 01/01/2024. First aid kit was observed to be complete.

At 1:30pm LPA reviewed 5 out 5 staff do not have First Aid nor CPR on files.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2024 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PACIFICA SENIOR LIVING UNION CITY	FACILITY NUMBER: 019200509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by 5 out of 5 staff did not have first aid or CRP on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2024
	Plan of Correction
1 2 3 4	Administrator will provided proof of all staff with current first aid and CPR to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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